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ATTACHMENT A DEPARTMENT OF HEALTH SERVICES COUNTY OF LOS ANGELES AUTHORIZATION FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION ___ Last Name First MI___ Date of Birth (Mo/D/Yr)___ Medical Record
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Start by addressing the recipient of the statement of disagreement request.
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Clearly state the reason for your disagreement with specific details and examples.
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Provide any supporting evidence or documentation that backs up your claim.
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Close the statement by requesting a resolution or further action to address the issue.

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A statement of disagreement request is a formal document submitted to contest or express a differing opinion regarding a specific decision or record.
Any individual or entity that disagrees with a particular decision or entry in a record that they have a legal right to challenge is required to file a statement of disagreement request.
To fill out a statement of disagreement request, one must provide personal identification information, clearly state the disagreement, outline the reasons for the disagreement, and include any supporting documentation.
The purpose of a statement of disagreement request is to officially document a differing perspective or correction against a record or decision, allowing for an opportunity for review or amendment.
The information that must be reported includes the individual's personal details, the specific entry or decision being contested, a clear explanation of the disagreement, and any related evidence.
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